Injuries and illnesses that keep from work can cause considerable personal and financial strain. At these times, individuals and families rely on insurance policies to keep them secure. When those benefits are denied, it’s natural to have many concerns and questions. Browse our FAQs to find information and insight from our experienced disability and injury attorneys.

An acceptable medical source is a person or institution that can provide evidence to support the existence of your disability. Such evidence must be in accordance with the Social Security’s guidelines, as set forth in SSA’s publication Disability Evaluation Under Social Security, which is also known as the “Blue Book.” The Blue Book contains information on all of the medical conditions that the Social Security Administration considers as potentially disabling and for which you may receive Social Security Disability benefits. In connection with establishing the existence, duration, and severity of a disabling condition, each listing includes medical evidence that must be submitted to the SSA by an acceptable medical source.

Licensed or certified psychologists. Included are school psychologists, or other licensed or certified individuals with other titles who perform the same function as a school psychologist in a school setting, for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning only;

Licensed optometrists, for purposes of establishing visual disorders only (except, in the U.S. Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only). (See paragraph (f) of this section for the evidence needed for statutory blindness);

Licensed podiatrists, for purposes of establishing impairments of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle; and

Qualified speech-language pathologists, for purposes of establishing speech or language impairments only. For this source, “qualified” means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence from the American-Speech-Language-Hearing Association.

The Social Security Administration’s “Program Operations Manual System” (POMS), section DI 22505.003, further illustrates the appropriate list of acceptable medical sources. In addition to evidence from the acceptable medical sources listed in DI 22505.003B.1., Social Security may also use evidence from other sources to show the severity of an individual’s impairment(s) and how it affects his or her ability to work or, for a child, the child’s functioning. Other sources include, but are not limited to:

We are often asked what to do immediately after a bicycle accident. Here what to do after a bicycle crash:

Safety First! Get to a safe location. Make sure that you are out of the way of moving traffic and that you are readily visible to oncoming traffic.

If you are injured, call an ambulance to take you to the hospital.

Call 911 to report the crash to law enforcement. If you are injured and taken from the scene for medical treatment, the investigating officer may meet you at the hospital. You may otherwise later regret not reporting the crash. Insist that a police report is made.

Note the investigating officer’s name, precinct and report number.

Request a copy of the Accident “Short Form” from the officer.

Gather as much information at the scene of the accident as you can. If you physically cannot do so due to your injuries, then have someone do it for you.

Take photographs of your bicycle, the vehicles involved in the accident and the surrounding area (roadways, traffic, etc).

Take photos of your injuries.

Preserve all property damage (your bicycle, helmet, damaged electronics, etc). Do not throw away or discard them because they are damaged. They may be necessary for evidence later.

Have your local bike shop manager assess and document the damage and provide an estimate for repair or replacement.

Write down the name of the at-fault Driver, Vehicle Owner, License Plate Number, Make, Model and Color of the vehicle.

Request and note the vehicle’s insurance information and the insurance policy number.

If the driver is not the owner of the vehicle, request the driver’s car insurance information as well.

If the accident involves a street or road defect, take a photo of it. Road conditions can change quickly or be repaired without notice.

Get the names and contact information for all witnesses, including their phone numbers, emails and mailing addresses.

A letter from your personal doctor or physician that states you are disabled and unable to work will not guarantee that your long term disability (LTD) claim will be approved. However, depending on the form and substance of the letter, such a letter can greatly improve your chances of being approved.

In most LTD cases, generic letters from physicians will have little impact on the insurance company’s disability decision. This is due to the fact that doctors submit letters that are so short and lacking in detail in most cases that the letter’s value to a disability examiner is practically non-existent. For example, if all the doctor does is summarize your medical diagnoses and conclude that you are disabled and unable to work, then that letter will not assist the claims handler in understanding why you are unable to work. Unfortunately, this type of letter is the most common one we see from disinterested physicians.

So what makes a good letter? We know that a detailed statement from a doctor who is knowledgeable about a claimant’s medical problems can make all the difference as to whether or not a disability claimant is approved for disability benefits. A good statement goes beyond reciting the patient’s medical diagnoses and gives an opinion as to the patient’s resulting functional limitations.

This type of statement is called a “medical source statement” or “residual functional capacity” evaluation. These medical source statements help in the evaluation process because most insurance company claims adjusters are not medical professionals. They rely on the medical professionals to identify the claimant’s level of impairment; therefore, adjusters give weight to detailed opinions of medical professionals, particularly those who are directly involved in the claimant’s medical treatment. The claims examiner should accept a treating doctor’s medical source statement as true and accurate unless they have good reason to reject it (such as where the doctor has no credibility or is not a specialist familiar with the claimant’s particular illness or injury).

To help a long term disability case, the doctor’s medical source statement should be:

detailed

objective, and

specifically assess the claimant’s physical capacity or mental capacity and the physical or mental limitations that result from the claimant’s medical condition and problems.

The statement should explain why the patient has certain limitations (for example, the patient cannot stoop because of a herniated disc in the back), and also be support by the medical evidence on record in the claim (for example, include an X-ray or MRI showing degenerative discs).

There is a form that accomplishes these goals, known as an RFC form. (RFC stands for residual functional capacity.) To learn more about RFC forms and to download one you can give to your doctor, see our downloadable RFC page.

The Social Security Administration (SSA) manages two programs that provide benefits based on disability or blindness, the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program.

SSDI provides benefits to disabled or blind individuals who are “insured” by workers’ contributions to the Social Security trust fund. These contributions are based on your earnings (or those of your spouse or parents). In order to qualify for SSDI benefits, you must have earned enough credits by paying your Social Security taxes as required by the Federal Insurance Contributions Act (FICA). Title II of the Social Security Act authorizes SSDI benefits.

Supplemental Security Income (SSI) (Title XVI) (Title 16)

The SSI program makes cash assistance payments to aged, blind, and disabled individuals (including children) who have limited income and resources. There is no work history requirement. The Federal Government funds SSI from general tax revenues. Many states pay a supplemental benefit to individuals in addition to their Federal benefits. Some of these states have made arrangements with Social Security to combine their supplemental payment with Social Security’s Federal SSI payment into one monthly check to you. Other states manage their own programs and make their payments separately. Title XVI of the Social Security Act authorizes SSI benefits.

Social Security Disability Insurance

Supplemental Security Income

Eligibility

A disabled individual must have paid Social Security taxes and earned enough work credits to become insured for benefits.

A disabled or blind adult or child must meet all of the following categories:
1. Have limited income;
2. Have limited resources;
3. Be a U.S. citizen or national (or in one of certain categories of aliens); and
4. Live in the United States or Northern Mariana Islands.

Payment

The monthly disability benefit amount is based on the Social Security earnings record of the insured worker.

The monthly payment is based on need and varies up to the maximum federal benefit rate. Some states add money to federal SSI payments.

Medical Coverage

The worker will get Medicare coverage automatically after receiving disability benefits for two years.

In most states, beneficiaries are automatically eligible for Medicaid.

The major difference between individual and group policies is that individual policies are underwritten with respect to the individual purchasing insurance coverage, while group policies are not individually underwritten. Instead, group policies are issued by disability insurance companies based on certain underwriting assumptions related to the general health of a group of people. Individual policies are typically bought and paid for by the insured, separate and apart from an employer. Group coverage, on the other hand, is usually offered by an employer or union, and the premiums are paid (in whole or in part) by the employer. There may be circumstances where an employer will purchase and pay the premiums for an individual policy on behalf of an employee. Conversely, an individual may personally obtain group LTD coverage unrelated to his or her employment by joining a group which has group coverage available for its members.

No. They are not the same. It is almost always better to have an individual policy over a group policy. First of all, the monthly benefits are tax-free if you pay the insurance premiums yourself. If the premiums are paid by a business employer, you may have to pay tax on the benefits. Moreover, if the insurance company does not pay a claim, your legal rights are very different with an individual policy than with a group policy. In short, your legal rights are much more favorable with an individual policy than with a group policy. For these reasons, you should purchase an individual policy over a group policy.

Your health insurance pays for your medical bills, but what about your other monthly expenses in the event that you are unable to work due to a disability? Disability insurance is meant to be a wage replacement in such cases where you cannot work due to a disability. An individual disability policy will typically pay you sixty percent (60%) to seventy percent (70%) of your monthly earnings leading up to the onset of your disability. You can purchase coverage that will cover you so long as you cannot perform the substantial duties of your own individual job, and you can buy coverage that will cover you for two (2) years, five (5) years, or until retirement age (typically age 65).

According to Black’s Law Dictionary, the definition of bad faith is: “The opposite of ‘good faith,’ generally implying or involving actual or constructive fraud, or a design to mislead or deceive another, or a neglect or refusal to fulfill some duty or some contractual obligation, not prompted by an honest mistake as to one’s rights or duties, but by some interested or sinister motive.” In contract law, there is the concept of “the covenant of good faith and fair dealing,” which means the insurance company has certain duties in carrying out its obligations according to the insurance policy contract. The following are examples of an insurance company’s bad faith after a policyholder files a claim for disability:

the insurer fails to conduct a reasonable and full investigation into the claim;

the insurance company acts unreasonably in evaluating the claim;

the insurer unfairly delays the processing of your claim;

the insurance company wrongfully denies the claim;

the insurance company unreasonably delays payment of benefits or pays less than the full value of benefits owed under the policy.

If your long-term disability claim is governed by ERISA, then you cannot sue for bad faith or punitive damages. This is because ERISA is a federal law that pre-empts state law claims such as bad faith and punitive damages. You can only sue for the benefits due.

An Experienced Disability Attorney Can Help You Navigate an ERISA-Governed Appeal

In ERISA disability litigation, the terminology used is a little different than “bad faith.” Federal courts will review the insurance company’s decision to determine whether the denial was “arbitrary and capricious.”

Without legal guidance from an attorney, claimants may unknowingly hurt their ability to prove the insurance company’s bad faith. For example, the claimant may allow the insurance company multiple opportunities to deny the claim by filing multiple appeals when multiple appeals were not required before making the carrier accountable in a lawsuit. As stated above, whether to appeal is a decision that you should make only after consulting with an experienced disability attorney.

The Ortiz Law Firm is dedicated to compassionate client service and outstanding results. Mr. Ortiz has a decade of experience in representing disability claimants in seeking benefits. The Ortiz Law Firm is not a “mill” firm that will represent just anyone that calls. The Ortiz Law Firm accepts approximately one in ten applicants that request legal assistance.

Mr. Ortiz has the support of a paralegal and an office manager, working together to deliver the highest level of legal representation.

If you have questions that are not covered in this section of LTD “Frequently Asked Questions,” call us at 850-308-7833.

ERISA is a framework of complex federal laws, regulations, and case law that apply to group disability claims. Most attorneys, including those who handle Social Security disability claims, do not have the knowledge or experience to properly handle an ERISA-governed LTD appeal or federal lawsuit. A general practice attorney may miss administrative deadlines or fail to address critical issues in the appeal process. Unrepresented claimants risk making the same mistakes. So my recommendation is Yes, you should consult with a lawyer in your LTD claim.

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From their Pensacola office, the legal team at the Ortiz Law Firm vigorously represents long-term disability clients all across the United States, as well as Social Security clients and personal injury victims in northwest Florida. Call our office today, or take a moment to fill out the contact form on this page to connect with the experienced legal team at the Ortiz Law Firm.

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